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- -- - APPLICATION FOR PERMIT- v - �SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anftegulations of the San Joaquin Local Health District. r Job Address �"U � M8 I( 1 TO n OC 10 City Lot Size PM Owner's Name b'n Gro SS Address S-/ ei Phone ` Contractor I wa lLl.-(' Address..- f"re0 /3ISY� lk. License No._a7 .5"SSIr}Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-I Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 W Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation}} ill serve: Residence Commercial_ Other Number owing units: Number of bedrooms CharacteC of soil to a depth of 3 feet: 'Cl tY Water table depth SEPTIC LANK Type/Mfg 92¢-L. CID A¢/e+f- Capacity 1/,n n No. Compartments PKG. TREATMENT PLT. ❑ - I Method of Disp sal Distance to nearest: WellI h n Foundation `..� Property Line 14160 7 LEACHING LINED r Total length/size No. & Length of lines -� Th FILTER BED ❑ Distance to nearest: Well�, t Foundation -70' Property Line_7E ' SEEPAGE PITS Depth 2s - Size - Number SUMPS ❑ Distance to nearest: WellTel r Foundation Property Line -7s� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require inspections. Complete drawing on reverse side. Signed X_ �✓ Title: rhe✓ -r Date: FOR DEPARTMENT USE ONLY Application Accepted by ' Dateilt Area Pit or Grout Inspection by Date 1 [ Final Inspection by Date (I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7114 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE y(� PERMIT NO. . EH Ia-]a IxEV-iixsl 7D -00 C� /��D 1. ( 2-75 EH 143a